Kara Atila, Akin Sakir, Ince Can
aDepartment of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The NetherlandsbDepartment of Intensive Care, Hacettepe University Faculty of Medicine, Ankara, TurkeycDepartment of Cardiology, Erasmus MC, University Medical Center, RotterdamdDepartment of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands.
Curr Opin Crit Care. 2016 Oct;22(5):444-52. doi: 10.1097/MCC.0000000000000335.
Critical illness includes a wide range of conditions from sepsis to high-risk surgery. All these diseases are characterized by reduced tissue oxygenation. Macrohemodynamic parameters may be corrected by fluids and/or vasoactive compounds; however, the microcirculation and its tissues may be damaged and remain hypoperfused. An evaluation of microcirculation may enable more physiologically based approaches for understanding the pathogenesis, diagnosis, and treatment of critically ill patients.
Microcirculation plays a pivotal role in delivering oxygen to the cells and maintains tissue perfusion. Negative results of several studies, based on conventional hemodynamic resuscitation procedures to achieve organ perfusion and decrease morbidity and mortality following conditions of septic shock and other cardiovascular compromise, have highlighted the need to monitor microcirculation. The loss of hemodynamic coherence between the macrocirculation and microcirculation, wherein improvement of hemodynamic variables of the systemic circulation does not cause a parallel improvement of microcirculatory perfusion and oxygenation of the essential organ systems, may explain why these studies have failed.
Critical illness is usually accompanied by abnormalities in microcirculation and tissue hypoxia. Direct monitoring of sublingual microcirculation using hand-held microscopy may provide a more physiological approach. Evaluating the coherence between macrocirculation and microcirculation in response to therapy seems to be essential in evaluating the efficacy of therapeutic interventions.
危重症涵盖了从脓毒症到高风险手术等一系列病症。所有这些疾病的特征都是组织氧合减少。宏观血流动力学参数可通过补液和/或血管活性化合物进行纠正；然而，微循环及其组织可能会受到损害并持续灌注不足。对微循环的评估可能有助于采用更基于生理学的方法来理解危重症患者的发病机制、诊断和治疗。
微循环在向细胞输送氧气以及维持组织灌注方面起着关键作用。基于传统血流动力学复苏程序以实现器官灌注并降低脓毒症休克及其他心血管功能不全情况下的发病率和死亡率的多项研究结果为阴性，这凸显了监测微循环的必要性。体循环和微循环之间血流动力学一致性的丧失，即体循环血流动力学变量的改善并未导致重要器官系统的微循环灌注和氧合得到相应改善，这或许可以解释为何这些研究未能取得成功。
危重症通常伴有微循环异常和组织缺氧。使用手持式显微镜直接监测舌下微循环可能提供一种更符合生理学的方法。评估治疗反应时体循环和微循环之间的一致性似乎对于评估治疗干预的疗效至关重要。
